P.O. Box 1095
Ellenwood, GA 30294
404-819-9007/770-769-6648
www.campextreme.org
email:info@campextreme.org
Child’s Name: ________________________Sex: F M Age:_____ Date of birth:____________ T-shirt size:_______
Home Address:______________________________City:____________ State:____________ Zip:______________
Home Phone Number:_________________________
Father’s Name:_____________________________ Cell Phone Number:__________________________
Father’s Place of Employment:__________________________ Work Phone:________________________
Employer’s Address:_____________________________ City:_______________ State:__________ Zip:__________
Mother’s Name:_____________________________________ Cell Phone Number:_________________
Mother’s Place of Employment:_______________________ Work Phone #:_________________________
Employer’s Street Address:_____________________City:_____________State:______Zip:______
Child’s Living Arrangements: (check one) ( ) Both Parents ( ) Mother ( ) Father ( ) Other
The child may be released to the person(s) signing this agreement or to the following:
*Name:_________________________________ Relationship to child:___________________
Address:________________________________ City:__________________State:________ Zip:_______________
Telephone Number:________________________Relationship to Parent(s) or Guardian:__________________
Other identifying information (if any):___________________________________________
*Name:_________________________________ Relationship to child:___________________
Address:________________________________ City:__________________State:________ Zip:_______________
Telephone Number:________________________Relationship to Parent(s) or Guardian:__________________
Other identifying information (if any):___________________________________________
Persons to contact in the case of emergency when parent or guardian cannot be reached:
Name:________________________ Telephone Number:_____________________
Name:________________________ Telephone Number:_____________________
Name:________________________ Telephone Number:_____________________
Please select the weeks that your child will attend:
May 31st____ June 6th_____ June 13th_____ June 20th______ June 27th______ July 5th_______
July 11th_____ July 18th______ July 25th______
I realize that camp tuition is $110 per week and is due on Monday of the week that my child will be attending.
There will be a $5 late fee for each day tuition is late and my child will not be allowed to return if tuition is not paid
by Wednesday.
Parent Signature:________________________________
Date:___________________
P.O. Box 1095
Ellenwood, GA 30294
404-819-9007/770-769-6648
www.campextreme.org
Name of Public or Private School child attends, if any: ________________________
Child’s doctor or clinic name:_______________________________________________
email:info@campextreme.org
Doctor/clinic phone # :_______________________
My child has the following special needs:__________________________________________________________
The following special accommodation(s) may be required to most effectively meet my child’s needs while at the
center: _____________________________________________________________________________________
My child is currently on medication(s) prescribed for long-term continuous use and/or has the following pre-existing
illness, allergies, or health concerns: _____________________________________________________________
___________________________________________________________________________________________
EMERGENCY MEDICAL AUTHORIZATION
I hereby give permission that my child__________________,may be given emergency treatment by a staff member at
Camp Extreme. Should (child’s name) _________________________Date of birth___________________
suffer an injury or illness while in the care of Camp Extreme and the facility is unable to contact me (us) immediately, it
shall be authorized to secure such medical attention and care for the child as may be necessary. I (We) shall assume
responsibility for payment for services and hold Camp Extreme and its employees harmless.
The licensee shall not be responsible for providing or paying for the child’s health care. I agree that neither I, or my child will bring any claims of any kind against Camp Extreme and its employees, as a result of injury,
expenses or damages that I or my child may suffer in any way related to the use of the facilities, toys, other children, teachers, whether such claims are know or unknown and arise in the future.
Parent/Guardian: ________________________________
Signature: _______________________________________ Date: ______________
FIELD TRIP PERMISSION
I hereby request that my child, __________________________________, be permitted to participate in field trips
and any other activity that would involve taking the child outside of the facility for his/her benefit, in attendance at this
facility.
Parent/Guardian: ________________________________
Signature: _______________________________________ Date: ______________
PHOTOGRAPH/VIDEOTAPE RELEASE
I hereby grant permission for Camp Extreme, to record the participation and appearance of my child,
_____________________________, by photograph and/or videotape in connection with camp activities for the
purposes of news releases, reporting, and assessing the progress of children and the program. Camp Extreme and its
contractors are authorized to exhibit or distribute such photograph(s) and/or videotape in whole or in part without
restrictions or limitations for any educational or promotional purpose that it deems appropriate. Such photograph(s)
and/or videotape may, for example, appear in printed or visual materials for Camp Extreme and/or on Camp Extreme’s
web site. The undersigned hereby jointly and severally releases, acquits, forgives, and discharges the camp provider,
Camp Extreme, and other entities contracted by the Camp Extreme, from any actions, agreements, claims, controversies,
demands, judgments, liabilities, proceedings, and suits, whether arising in equity or in law regarding such participation and
appearance by said child. This release shall remain binding upon all successors in interest and personal representatives of
the parties, to the extent permitted by law.
Parent/Guardian: ________________________________
Signature: _______________________________________ Date: ______________
Facility Administrator/Person-In-Charge
Signature:_______________________________________ Date:_______________
P.O. Box 1095
Ellenwood, GA 30294
404-819-9007/770-769-6648
www.campextreme.org
email:info@campextreme.org
CAMPER HEALTH HISTORY
Child’s Name:________________________
DOB:____________
REQUIRED IMMUNIZATIONS
All campers must be current on all immunizations, unless they provide a written statement from either a
licensed physician indicating that the immunization is medically contraindicated, or the parent or guardian
indicating that they object to immunizations for religious reasons.
A. Date (month and year) of camper’s last tetanus or (DTP) shot___________
B. Is camper currently enrolled in a Georgia school, public or private? Yes_____ No______
C. If B is no, furnish a record of immunizations for diphtheria, tetanus, pertussis, poliomyelitis, measles
(rubeola), rubella (German measles), and mumps.
D. Is camper exempt from immunization on medical or religious grounds? Yes_____ No_____
Physician’s Name:___________________________ Phone Number:_________________
HEALTH INFORMATION: Are there any special needs, medical conditions, or behavioral
conditions that we need to be aware of to ensure that your child’s camp experience is positive.
Check any that apply and give more information.
_____Good general health
______Seizure
_____Allergy, food or other
______Behavioral issue
_____Asthma
______Significant mental health condition
_____Diabetes
______Prescription medication
_____Other chronic health condition ______Other medication
Explanation:__________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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